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the truth about the Parliamentary and Health Service OmbudsmanThu, 05 Sep 2019 09:16:08 +0000en
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3232David Czarnetzki, open letter to Philip Dunne MP, is PHSO fit for purpose?https://phsothetruestory.com/2019/09/05/david-czarnetzki-open-letter-to-philip-dunne-mp-is-phso-fit-for-purpose/
https://phsothetruestory.com/2019/09/05/david-czarnetzki-open-letter-to-philip-dunne-mp-is-phso-fit-for-purpose/#commentsThu, 05 Sep 2019 08:55:25 +0000http://phsothetruestory.com/?p=845My name is David Czarnetzki and my issues concerning the conduct of the Parliamentary and Health Service Ombudsman have now been ongoing for over four years. The following letter was handed to my Member of Parliament, Philip Dunne at his constituency surgery on 30thAugust 2019.

The detail should impart on the reader a need for extreme caution in pursuing a health service complaint via this particular body. In 2015, the Patients Association described this organisation as “unfit for purpose”.

Read my story. You may well conclude it still is.

30th August 2019

Philip Dunne MP

House of Commons

London SW1A 0AA

Dear Philip,

Open letter regarding the conduct of the Parliamentary and Health Service Ombudsman (PHSO)

You will now recall the issues first raised with you in July 2015 following the publication of a final report, by PHSO on 22ndJune 2015, concerning my earlier treatment at Telford Hospital during 2013 and 2014. You corresponded with PHSO on three occasions in 2015 and, on each occasion, received no response from them. I have since been forced to embark on a determined, tenacious and sustained process to uncover the extent of the failings encountered at Shrewsbury and Telford NHS Trust and also those at PHSO. The PHSO failings are the focus of this letter and fall into three main categories.

Refusal to quash the June 2015 final report

You will see from the core documents on the file that Rob Behrens the Ombudsman admitted, in a letter dated 9thApril 2018, his June 2015 final report came to the wrong conclusion. Since then I have been requesting the report be quashed. In his letter to Sir Bernard Jenkin, dated 1stFebruary 2018, Mr. Behrens confirms he has powers to quash a final report yet has failed to do so in this case. He has refused to explain why or enter into correspondence on this matter. His refusal to quash a report recognized as ‘flawed’ needs to be questioned at a parliamentary level.

His decision not to quash the final report has the following consequences:

Behrens has portrayed me as an individual who made an unsubstantiated complaint in the eyes of Shrewsbury and Telford NHS Trust. I have strong objections to, and resent, being left in this position.

The Trust has not been contacted by the Ombudsman and therefore never had an opportunity to learn from the issues raised since the flawed June 2015 report was published. You will be aware this particular NHS Trust is subject of various enquiries into the standard of some of its services and I must confess some sympathy for the relatively new Acting Chief Executive who may well be doing her best to improve things. Incorrect reports absolving the Trust, published by PHSO, can only hamper any genuine effort the Trust CEO makes to create better outcomes.

If the Ombudsman is prepared to leave this incorrect report in the public domain, it then becomes legitimate for complainants, NHS management, clinicians and politicians to suspect and question the level of thoroughness and accuracy in every report he issues including, may I say, his Annual Report which is subject to scrutiny by the Public Administration and Constitutional Affairs Committee (PACAC). It is now fair to say that, if the Ombudsman is prepared to conduct himself in this way in one case, he is prepared to behave in the same way in other cases to users of his service whether they are a complainant or respondent. The very credibility of the Ombudsman is at stake and Mr. Behrens remains at the head of a discredited organisation as previously identified in the Patients Association report issued in 2015.

Failure to comply with procedures for resolution

PHSO, on its website, issues guidance on principles of good complaint handling. The outset of this document clearly states; “We will also apply the Principles to any complaints made to us about our own service”. Section 5 covers points to consider when deciding an appropriate level of compensation. These are:

The nature of the complaint

The impact on the complainant

How long it took to resolve the complaint

The trouble the complainant was put to in pursuing it.

PHSO guidance goes on to say; “Remedies may also need to take account of any injustice or hardship that has resulted from pursuing the complaint as well as from the original dispute”.

The PHSO letter of 9thApril 2018 offered me £1000. There was acknowledgement I have suffered injustice and PHSO would have awarded this sum against the NHS Trust had his final report of 15thJune 2015 accurately reflected the treatment I received. The letter also offered, in addition, a token sum of £500 to cover PHSO’s own poor complaint handling, but this part of the offer failed to demonstrate how his own guidelines on compensation levels were taken into account. My reply dated 11thApril 2018, to the PHSO letter of 9thApril, was ignored and after a further six weeks I felt compelled to issue proceedings in the County Court. The proceedings were to be primarily concerned with the conduct of the Ombudsman and not his decision regarding the belated award he made against the NHS Trust which, due to the passage of time and the fact that the original report had not been withdrawn, made legal action against the NHS Trust impossible. Subsequent to the issue of legal proceedings, there was an arbitrary improved offer by PHSO to settle the matter for a total sum of £2000. Bearing in mind I had by now spent £205 on Court fees, this represented a real increase of £295 over the offer in the letter of 9thApril and still failed to show any compliance with his stated policy on points to consider in calculating financial remedy.

The Court Action

My claim against PHSO, amounting to £4537, consisted of £3800 damages, £532 interest in line with Court rules and £205 costs. PHSO filed an acknowledgement of service with the Court on 12thJune indicating an intention to defend the claim. There then followed an astonishing sequence of events.

Despite the in house legal expertise at their disposal, PHSO failed to properly comply with Court procedure and, on 31stJuly 2018, the Court issued a Judgment in Default against PHSO ordering them to pay me the total sum of £4537. Feeling vindicated, I awaited settlement in accordance with the Court judgment but unaware this appalling organisation had yet to finish compounding my misery.

One must ask how PHSO allowed the Judgment in Default to occur. Their next step was to apply to the Court to have it set aside and my original application struck out.

The first hearing was set for Telford County Court (small claims process) on 31stDecember 2018. PHSO engaged a barrister from 39 Essex Chambers. The Judge agreed the Judgment in Default should be set aside but gave leave for me to re-submit my original application with additional supporting evidence. There was no direction by the Judge at this hearing that the small claims route was not open to me to pursue my claim.

The second hearing took place at Telford County Court on 30thJuly 2019 with a different barrister from the same chambers representing PHSO in front of a different Judge. This time, the Judge ruled he had no jurisdiction to hear the case and the application by PHSO to have the matter struck out was successful. However no costs were awarded.

The evening before the second hearing, an email timed at 1859 hours 29thJuly (just 15 hours before the appointed hearing) was sent to me by an in house lawyer of PHSO. The email reads; “On reviewing the documents in your case we note you have referred to a statement dated 10 November but we are unable to trace this. Could you please send a copy of that statement by email before the hearing tomorrow”.

I complied with the request. However, it raised further issues. 153 pages of evidence PHSO should have been considering before the first hearing accompanied my statement of 10thNovember 2018. I was also concerned that significant personal data had now gone missing. PHSO have since provided proof to my satisfaction they have the data and issued yet another of their insincere apologies, the total number of which now runs into three figures, each becoming less meaningful than the last.

Action required

I seek your re-involvement and have two requests:

That you write to the Acting Chief Executive of Shrewsbury and Telford NHS Trust, enclosing this letter and the letter of 9thApril 2018 signed personally by the Ombudsman, Mr. Behrens. Your letter should invite her to return the PHSO final report dated 22ndJune 2015 to him. That action alone will at least demonstrate some integrity exists within the Trust and that the new Acting CEO is not prepared to be part of what can only be described as a PHSO cover up which has taken me over four years to expose. I can confirm the Trust is at no risk of legal action from me. My reason for initially going to PHSO was to avoid having the issue of my treatment dealt with at Court.

That you personally meet with Sir Bernard Jenkin, Chair of PACAC, and discuss the ramifications of this case with him. You should also hand him the complete file of case papers in order to demonstrate that, despite the scrutiny of PACAC, nothing has yet changed for the better within the PHSO framework. The fact that Mr. Behrens is quite prepared to leave in circulation a final report he has identified as inaccurate should be enough for Sir Bernard and Mr. Behrens to consider whether his position as Ombudsman and also the position of his Chief Executive remain tenable. I am quite prepared to accompany you at such a meeting. I do not expect this matter to be sidelined citing previous comments of Committee Clerks in correspondence that PACAC does not look at individual cases. PACAC has done so in the past and has taken oral evidence in some. The public might have a better Ombudsman Service if PACAC takes a greater interest in individual cases in the future.

I do have to say that, having personally attended the last scrutiny hearing of PHSO by PACAC in January 2019, I was disappointed to see the session lacked understanding, depth and incisiveness, particularly as so many people had made written submissions and also took the trouble to attend. It is worthy of note that, despite Mr. Behrens refusing to engage with the co-ordinator of the support group PHSO-The Facts, at least fifteen new people have joined this group in recent months as a result of their experiences at the hands of PHSO. I have seen that PHSO seeks greater own initiative powers and yet resists greater oversight of its work, stating this would undermine the authority of the Ombudsman. This must be resisted if a PHSO “mini dictatorship” within our democracy is to be avoided. It is clear the process of peer review and PACAC scrutiny is not bringing improvement and a wider, independent public enquiry into PHSO must now be carried out.

There is one final comment I wish to make and that is in relation to the offence of Misconduct in Public Office (MIPO). If in the event Mr. Behrens or any other person makes a suggestion the Police have found no evidence of misconduct in public office within his organisation, I have to point out that would not be an accurate statement. Letters in my possession from the Metropolitan Police indicate that, according to legal advice they have received, they are prohibitedfrom conducting investigations into PHSO of MIPO by virtue of the legislation controlling the operation of PHSO. That is not the same as saying MIPO has not taken place. This is also something for PACAC to consider and address as it leaves all employees at PHSO immune from prosecution in the event of any willful or deliberate misconduct on their part.

PACAC should be asking the question as to whether it should be necessary for the sledgehammer of a Judicial Review to be sought to crack what was, in this case, a miniscule peanut of two parties being £1800 apart in their positions regarding compensation.

I see no point in your writing to Mr. Behrens again as he ignored your correspondence in 2015 and much of mine in the intervening period. I await your response, asking you to send me a copy of any letter you write to the Acting Chief Executive at Shrewsbury and Telford NHS Trust. Bearing in mind this is an open letter I intend to circulate widely, I will be pleased to also circulate your response to it. It is clear from this case PHSO maintains its ability to fail at every level be it investigative, administrative, legal or executive.

Yours sincerely,

David Czarnetzki

]]>https://phsothetruestory.com/2019/09/05/david-czarnetzki-open-letter-to-philip-dunne-mp-is-phso-fit-for-purpose/feed/25Screenshot 2019-09-05 at 10.14.30phsothefactsRegulatory capture – worse than no regulator at all.https://phsothetruestory.com/2019/05/25/regulatory-capture-worse-than-no-regulator-at-all/
https://phsothetruestory.com/2019/05/25/regulatory-capture-worse-than-no-regulator-at-all/#commentsSat, 25 May 2019 16:20:38 +0000http://phsothetruestory.com/?p=841The Parliamentary and Health Service Ombudsman(PHSO) is technically not a ‘regulator’ but it sits in the place of a regulator, holding public bodies to account. With just a 3% uphold rate from all complaints submitted in 2017/18 this is a body which ticks all the boxes for ‘regulatory capture’. With a revolving door between the Ombudsman and the bodies under their remit, a lack of transparency and no public accountability the PHSO legitimises poor public services across government and the NHS whilst extending the stress of injustice for members of the public who make a complaint.

Regulatory Capture – Definition And Meaning

Regulatory capture occurs when a government’s regulatory agency, which was created in the public interest, ends up advancing the political or commercial concerns of the very people, companies or entities it is supposed to be regulating. Regulatory capture, in the world of government monitoring, is like when the gamekeeper turns poacher, or at least, assists the poacher.

Regulatory capture is a form of government failure. Government failure, also known as non-market failure, is imperfection in government performance. Regulatory capture is a form of rent-seeking – trying to get a larger slice of a market’s total wealth without creating any additional wealth for that market.

When regulatory capture exists, the interest of political groups or companies become more important than those of the public, which leads to a net loss to society.

If you are having problems because the wolves keep eating the sheep, perhaps setting up an agency might help protect those sheep. However, you have a problem if the only individuals qualified to become agency members are also wolves.

To define captured agencies refers to the government agencies that suffer regulatory capture.

How pervasive is regulatory capture?

Regulatory capture theory was set out by Prof. Richard Postner, an American jurist and economist, who is a Senior Lecturer at the University of Chicago Law School and also a judge on the US Court of Appeals for the Seventh Circuit in Chicago.

Prof. Postner argued:

“Regulation is not about the public interest at all, but is a process, by which interest groups seek to promote their private interest… Over time, regulatory agencies come to be dominated by the industries regulated.”

While warning that there is always a risk of regulatory agencies being captured by the very firms that they are supposed to be policing, the majority of economists’ views are less extreme than those of Prof. Postner.

Why does regulatory capture occur?

According to public choice theorists, individuals and groups with high-stakes interest in the outcome of a specific policy or regulatory decision will naturally focus their energies and resources in trying to obtain the policy outcomes that best suits them, while the rest of society – members of the public – each with only a minuscule individual stake in the outcome, are likely to ignore it completely.

When regulatory capture occurs, agencies may find themselves chasing their own tails, running in circles, and sometimes even backwards. Riddled with conflicts of interest, they no longer accomplish what they were set out to do – to protect members of the public (consumers).

Regulatory capture occurs when the actions of individuals, companies and interest groups are successful at ‘capturing’ influence with regulatory agency staff or commission members.

The probability of regulatory capture is a risk which all agencies are exposed to because of the very nature of their **environment. This suggests that all regulatory agencies should be shielded from outside influence as much as possible.

** In the pharmaceutical and medical world, for example, the regulatory agencies – such as the FDA in the US, the MHRA in the UK, and the EMA in the European Union – are staffed with experts in their field. This means that they must have worked in medicine and/or the pharmaceutical industry – the very environment they are supposed to be policing. Industry lobbyist know these experts very well – they all come from the same place.

‘Captured agency’ worse than no agency

An alternative, say many critics, is not to create the regulatory agency in the first place, then the risk of regulatory capture is reduced to zero. In most cases, a captured regulatory agency is worse for the overall good of society than no regulation at all – as soon as the industry is in control of the regulatory agency, it has the power of government.

The more transparent agencies are, the less effective are the effects of capture. However, even **transparency and press freedom are often not enough.

In a World Bank Policy Research Working Paper – ‘Small is Beautiful, at Least in High-Income Democracies’ – Alexander Hamilton writes that according to recent evidence, even in the world’s wealthiest democracies with high levels of media freedom and transparency, the more complex and extensive regulatory environments are associated with greater levels of corruption, including regulatory capture.

When the employees who are in the industry, its lobby groups, and its regulatory agency are all the same people, the likelihood of regulatory capture existing is enormous. However, if as in the image above, the FDA wants top experts, there is only one place it will find them – within the industry.

“If Hanson is right, the success of the Law & Economics movement in US law schools is less a function of its theoretical strength than it is a function of the fact that it favours elites, a number of whom have funded conferences, journals, professorships, and even law school buildings, in order to allow a shoddy theory to emerge as though it were the winner in a neutral marketplace of ideas.”

Prof. Milton Friedman discussing government regulations:

In this YAF TV video, Prof. Milton Friedman says: “Government regulation is always undertaken to benefit consumers. It is always undertaken under pressure from the producer – and it ends up having the opposite effect. This is the law of unintended consequences – the law that is intended to benefit consumers will end up benefiting producers.”

]]>https://phsothetruestory.com/2019/05/25/regulatory-capture-worse-than-no-regulator-at-all/feed/12Screenshot 2019-05-25 at 17.17.14phsothefactsRegulatory captureRegulatory capture - unrolling and rolling up the carpetRegulatory capture - they are all the same peopleA perception of injustice aka gaslighting.https://phsothetruestory.com/2019/05/17/a-perception-of-injustice-aka-gaslighting/
https://phsothetruestory.com/2019/05/17/a-perception-of-injustice-aka-gaslighting/#commentsFri, 17 May 2019 20:34:05 +0000http://phsothetruestory.com/?p=837If you have ever made a complaint about a public body the chances are your valid complaint will be referred to at some point as a ‘perception of injustice’ as if your experiences are just illusionary. Gaslighting is commonly used to deflect criticism and deter persistent complaint. So when you are up against authorities in collusion to deny the facts, knowing that others can validate your experiences with their own life events is vital to maintaining your mental stability.

Tactic #1: Gaslighters override your reality.

At its heart, gaslighting is overriding your reality to the point that you question your own judgment. Like most things, there are degrees. It can be as small-scale as telling a child, “You can’t be hungry—you just had a snack,” or as large-scale as denying fully obvious facts, such as this 2015 story about a man who got married, posted the wedding photos on Facebook, and then told his long-distance girlfriend it was a figment of her imagination. To sum up, if the gaslighter had a mantra, it would be, “If you repeat a lie often enough, it becomes truth.”

Tactic #2: Gaslighters aren’t out to destroy you; they’re out to make things easier for themselves.

Unlike in the movie, most gaslighters aren’t pursuing anything as concrete as a treasure chest of jewels. What they want is more psychological. The gaslighter wants control of the target on a specific set of terms, with the gaslighter in charge. For the same reason, gaslighting isn’t always conscious. Indeed, gaslighters don’t sit around stroking their goatees or petting a white cat while plotting to undermine your sanity. Instead, gaslighting comes from the need—conscious or unconscious—to control. Gaslighters work to undermine you so you can’t challenge them. Then the relationship can go the way they want. They get to have their cake and eat it, too, without the inconvenience of having to discuss things, compromise, or work together.

Tactic #3: Gaslighting is often fueled by sexism.

Of course, gaslighting can be used by anyone against anyone—it’s not always gendered. But it’s often used as a form of emotional abuse against women. It “works” in part because it feeds off sexist stereotypes of women as crazy, jealous, emotional, weak, or incapable. For example, in an excellent 2014 paper published in Philosophical Perspectives, Dr Kate Abramson of Indiana University details a story where a female grad student discovers the male grad students have made a list ranking the female grad students by attractiveness. When she expresses that such a list is inappropriate, she is told she’s overly sensitive, that she’s policing innocent conversation among male friends, and really she’s just insecure about her ranking on the list, isn’t she? By not allowing their sexist behaviour to continue unchecked, the male students suggest she is acting like the stereotypical “crazy woman.”

What just happened there? If a woman rings the alarm on sexist behaviour, gaslighters use sexist stereotypes to undermine the woman’s complaints. Instead of taking her seriously, each of her complaints might be refuted as a silly misinterpretation or dismissed as her being too sensitive. In this way, the sexist stereotypes are used to reinforce themselves—an uninterrupted pattern of circular logic: “See, she’s just another insecure, overly emotional woman we don’t have to listen to.”

Tactic #4: Gaslighters make disagreement impossible.

Once you are discredited, any argument you may have is casually written off. When credibility is undermined — you’re crazy, a liar, unstable, a failure, or have lost your mind—anything you say is automatically suspect and builds the case against you. Therefore, you can’t disagree or protest. And the louder your objections, the more your gaslighter can smile smugly and say, “See, I told you so.”

Tactic #5: Gaslighters make you agree with their point of view.

Gaslighters need the world to conform to their standards. And they need the very individuals they gaslight to agree with them. Therefore, it’s not enough for gaslighters, for example, to insist that sexual harassers were just having a little fun. They need the target of the harassment to agree that it was all just a little fun. Ideally, the target would not only agree but also believe that she deserved to be undermined because she was being crazy, overly sensitive, or imagining things. Now, refusing to witness or substantiate your reality is invalidation. But gaslighting means getting you, the target, to invalidate yourself as well. Not only does no one take you seriously, you wonder if you can take your own experience seriously: your common sense, your feelings, your memory, even what you’ve seen before your very eyes. In other words, gaslighting not only invalidates your experience, it also makes you question your capacity to trust your experience in the first place. At this stage, your gaslighter has you right where they want you: beginning to doubt yourself and your ideas even when they’re not there to continue enforcing the message.

As for Ingrid Bergman as Paula, she is validated in the end and Gregory is arrested, but not before she dishes out some gaslighting revenge of her own as he sits tied to a chair. In a final attempt to manipulate her, Gregory tells her to get a knife and cut him free, but as she pulls his knife from a drawer she proclaims, “There is no knife here; you must have dreamed you put it here,” before tossing it away and quipping, “I am always losing things.”

Whether in Hollywood or your own household, gaslighting is a form of emotional abuse. Isolation is a key ingredient to gaslighting, so if this article spoke to you, reach out. Having just one person validate your experience can be a lifeline that begins the process of reeling yourself in from all the lies to believing your own truth again.

“…this post outlines a Manifesto for Ombudsman Reform based upon a roundtable discussion at the University of Sheffield in January 2019. A cross-section of stakeholders to the ombudsman community participated in the event…”

It was refreshing to see references to the service user viewpoint in this report but we were not part of the cross-section of stakeholders invited to the event where our voice could have contributed to the construction of the manifesto. There is a certain irony in the final recommendation considering that the academics themselves failed to directly ‘incorporate the views of users’ in their decision-making process.

7. The office [PHSO]should be challenged to evidence its capacity to assist all sections of society and incorporate the views of users and investigated bodies into the design of its decision-making processes and setting of standards.

The reality is that the views of the service user are rarely sought, yet when they are, these views give a consistent narrative and central to that narrative is the claim that the Ombudsman is biased against them.

1983

In an article in the New Society in 1983Whose side is the Ombudsman really on? Paul Burgess cites examples of bias such as relying on the information provided by the public body without cross-referencing with the complainant; information which turned out to be flawed and the repeated use of ‘accommodating observations’ to put the public body in the best light. He concluded that;

At grassroots level, I believe the ombudsman scheme has been a failure. It does not offer the ordinary citizen a satisfactory remedy against administrative abuses; indeed, it has become a part of the oppressive network of official institutions which, though purporting to offer public service, have effectively acquired purposes and justifications of their own.

2014 – 2016

Between 2014 to 2016 the Patients Association released three damning reports into the Ombudsman service. Recording the views of over 200 service users, 66% stated that there was ‘weak justification’ for the PHSO decision and 62% reported that PHSO ignored or overlooked the evidence, apparently siding with the Trust.

2015 – 2017

Lack of impartiality was a key issue in research carried out by Gill and Creutzfeldt in 2015 and reported in 2017 which looked at the views of on-line critics of Ombuds services.

Lack of impartiality (the ombud siding with the public body), lack of transparency (private deliberations) and lack of robust inquiry are the key criticisms identified. Watchers refer to lack of opportunities for face-to-face interaction, interviews, fieldwork; they suggest that the paper-based approach is inevitably weighted against the citizen, as control of official records are in the hands of the public body. Ombuds are experienced as emotionally and professionally attached to public bodies and their staff rather than to citizens. The form of expectations management used by ombuds is seen as patronising and concerned more with KPI issues (speed, cost, politeness) than with questions of justice. The ombud is seen as a ‘pseudo-system of administrative justice’.

2017

In 2017 Martin Lewis from Money Saving Expert carried out a consumer review of Ombudsman services and released a report called Sharper Teeth Approximately 100 people supplied data concerning PHSO and 75% claimed that the Ombudsman appeared biased towards the other party. (p59)

2018 – 2019

Completed in December 2018 but released without fanfare in March 2019 the clinical advice review gives a rare insight into the investigation process at PHSO. Sir Liam Donaldson was able to internally assess how PHSO gathered and utilised expert clinical advice when making decisions on clinical care complaints. He spoke with caseworkers, clinical advisors, management and importantly, talked directly to service users plus access to written contributions from complainants. His report revealed a number of unpalatable facts which exposed the ways in which error is allowed to permeate the process without proper check and balance.

Given that the Ombudsman has been able to investigate health complaints since 1973 and was empowered to investigate clinical judgment from 1996 the opening statistics given by Sir Liam are a shocking indictment of the value of this service.

Just one example illustrates the ineffectiveness in system level learning and improvement. Recently, the government’s Health and Social Care Secretary commissioned a major academic study of the prevalence of medication error in the health service in England (6). This showed that an estimated 237 million errors occur at some point in the medication process each year. Yet, most categories of medication-related harm that happen today were delineated in a study in 1961 (9). No other major high-risk industry has such a poor record of safety improvement. (p4)

There were around 208,000 written complaints made to the NHS in England in 2017/18 (10). This equated to about 572 per day. There is no information available to show how these complaints align with each of the six sources of poor quality or unsafe care. There is little information to show how complaints are used to systematically improve in these areas of quality and safety. (p4)

Just what has the Ombudsman been doing in all this time? By casting an external eye over the procedures, Sir Liam was able to identify the ways in which the prescribed ‘process’ failed to meet the core objectives of protecting the citizen.

The handling of complaints by the PHSO service is very procedurally driven. In part, this is because of legislation governing the PHSO role in NHS complaints, in part because of internal procedures, both written and unwritten. Both are underpinned and reinforced by the induction, training and supervision of the organisation’s staff. Generally, close adherence to these procedures is important and a good thing but not when they do not serve a necessary wider purpose (e.g. of safeguarding future patients from harm) or when they discourage thinking and common sense reasoning (e.g. not taking up a serious concern about care because it is not one of the strands of the complaint) or when they confuse and upset too many complainants. Some staff are very protective of the current procedures and seem to hold the belief that, because of the statutory role of the PHSO, little can be changed. (p9)

PHSO has no external scrutiny of its investigation procedure and is, therefore, able to operate in ‘a self-confirmatory bubble’ which is beyond challenge. The dangers of this were immediately apparent to Sir Liam.

On reading the judgement, [Miller & Anor V Health Service Commissioner] it is a perfect example where the internal world and the external world see things differently. Those handling the complaint believed themselves to be following the normal rules, customs and practices. Yet, the account of the Appeal Court Justices on the handling of the complaint brings an entirely reasonable expectation from the external world that decisions and actions should be appropriate and fair. The PHSO’s team in this case believed that their work was procedurally sound. Impartial scrutiny found that they were not. P10

‘…an entirely reasonable expectation from the external world that decisions and actions should be appropriate and fair’ is a very telling phrase as is the fact that the PHSO team believed their work to be procedurally sound when it was found to be ‘irrational to the point of illegality’.

When meeting with service users and consulting the complainants written evidence the issue of bias once more topped the league table of complaint.

It is striking, that in the Clinical Advice Review Team’s meeting with complainants, there was a widespread view that the PHSO would take sides with, or protect, the NHS organisation complained against, or fail to challenge the provider of care robustly enough. (p11)

Accusations of bias, secrecy, insensitivity, error and failure to listen, occurring as they did, in the period before this Clinical Advice Review was commissioned are extremely important in considering what changes now need to be made. One way or another, the process of clinical evaluation of complaints is interwoven with such criticisms and concerns. (p12)

Sir Liam then cites a number of ways in which ‘error’ permeates the process such as the lay caseworker making assumptions which then affect the quality of the evidence provided by the clinical advisor. Or the caseworker failing to provide key evidence to the clinical advisor, failing to take heed of warnings given by the clinical advisor or failing to include harmful acts by scoping them out of the investigation altogether. He concludes;

Overall, based on my review of cases, together with my discussions with staff and complainants, I judge that the current process of commissioning and use of clinical advice is prone to three types of error: errors of fact, errors of interpretation, and errors of omission. (p18)

The current procedures have clear problems with a real risk of drawing the wrong conclusions. (p20)

Sir Liam stresses the importance of listening to public criticisms of PHSO which include those made prior to the appointment of Rob Behrens.

These may be thought of as past events of no direct relevance to the current Clinical Advice Review. This would be a mistake. Addressing their underlying causes and dysfunctions is essential to the new PHSO continuing to implement his reforms whilst retaining the confidence of patients and the public. These past criticisms echo many of the risks that are quite clear in the present handling procedures for complaints. Also, the negativity from these events is swirling around the present service, even though it has made a fresh start under the new PHSO. Moreover, the complainants, with whom the Clinical Advice Review Team met, brought serious concerns about their cases to the meeting. Their experience was consistent with the previous criticisms. Although information is available on people who were satisfied with the PHSO’s work, the complainants who responded to the consultation should not be regarded as an unrepresentative minority. Changes to the current way of working should be such as to restore confidence in the PHSO’s ability to get right the assessment and investigation of complaints. Errors should be rare. There should be no hint of bias towards NHS bodies. Complainants should feel fully engaged in the process. (p19)

‘These past criticisms echo many of the risks that are quite clear in the present handling procedures for complaints’.Many of these past criticisms emanate from members of PHSOtheFACTS who have repeatedly tried to alert both PHSO and PACAC to the failures now identified in Sir Liam Donaldson’s report. Calls for reviews have been repeatedly denied by Rob Behrens on the basis that the decisions in our cases were sound despite the fact that in the recent Value for Money report the staff reported that “previously, performance management had been too driven by artificial targets and process, rather than a concern with the quality of decisions being reached” (6.4 p21) and despite the fact that the Miller & Anor case demonstrates the inability of PHSO to accurately evaluate its own performance. Following this judgement against PHSO it was reported that the use of clinical expertise had been dysfunctional for at least 8 years, hence the call for Sir Liam’s clinical advice review.

The following correspondence between Rob Behrens and Sir Bernard Jenkin chair of PACAC sent on 23 rd February 2019 refers to a meeting held in October 2017 with members of PHSOtheFACTS. This correspondence is an attempt to close down all prospect of independent, external review of our unresolved cases.

Dear Sir Bernard,

I cannot let the email to you from [REDACTED] pass without comment. Leaving aside his accusations of corruption and ‘abusive’ letters, I draw your attention to the basic issues in this case:

1. [REDACTED] was one of more than 30 families I agreed to meet in October 2017;

2. I listened to their stories and agreed to look again at their historic cases with an assurance process involving a senior colleague who had no previous involvement. This involved a significant amount of work;

3. As I reported to PACAC in January a very small number of those cases were found to have unreliable decisions and were/ are being looked at again;

4. [REDACTED] case was not. You have the letter I wrote to him at the time.

5. Along with others, [REDACTED] then called for an ‘external independent review’ but as I have always maintained, the Ombudsman is the external independent review and anything else – leaving aside unprecedented, very rare circumstances – undermines my authority and my relationship with Parliament.

Yours sincerely,

[REDACTED]

Mr Behrens reviewed the case files presented to him, informed us that he was ‘horrified’ by the contents but later found that just a few cases needed closer review. These few cases remain in the PHSO system without resolution, despite on-going reviews which have lasted over 18 months. It is clear that without independent scrutiny of these cases inherent, institutional bias will not be identified.

Sir Liam stressed the validity of the claims made by the service users to confirm they were a ‘representative group’. He also found that the views he heard at the roundtable meeting reflected the same views he had seen in the written evidence. This demonstrates a consistent narrative despite the fact that no PHSOtheFACTS members were present at the meeting to influence the debate.

It would be wrong to simply note the critical comments and conclude that they were an unrepresentative minority. The sources of information on complainants’ experience provide rich and important insights into the functioning of the PHSO service. It was particularly striking that the group of complainants, with whom I, and the Clinical Advice Review Team, met, was not made up of vexatious or unreasonable people. They expressed frustration and, anger, but the problems that they described with the handling of their complaints should be a vital source of learning. Many of their criticisms of the PHSO’s processes, and those in the documented accounts and submissions, were consistent with what I had already observed, having read a sample of records provided to me. (p13)

Since Rob Behrens became the Ombudsman in 2017 access to justice has been reduced. Firstly, through a reduction in the number of investigations. written evidence to PACAC 2018

5.3. Between October 2017 and June 2018 the PHSO completed just 1398 investigations, a reduction of 52% from the same period in the previous year when 2929 investigations were completed.

5.4 The performance statistics for the July to September quarter have now been released and only 440 health investigations were carried out during this period compared with 991 during the same period of 2016-17, a reduction of 55%, and only 271 complaints were upheld or resolved compared with over 400 during the same period of 2016-17, a reduction of more than 30%. Clearly performance is not “fully back on track” as promised by Amanda Campbell and the “many areas” of “improving performance” identified by the Value for Money Study remain elusive.

5.5 The percentage of complaints being assessed as suitable for investigation or resolved has also dropped from 47% to 31%. In other words complaints which would have been accepted for investigation in 2016-17 are now being rejected. Is this a deliberate policy?

5.6. The increase in complaints being resolved at assessment does not compensate for the large decrease in the number of investigations being carried out. It is important for public confidence that the public is informed as to whether this reduction in the overall number of investigations and resolutions is permanent.

All external review of Ombudsman decisions has been removed including the oversight given by the ‘quality assurance associates’.

1 & 2. There are currently no external quality assurance associates
operating within PHSO.

3. For the business year 2017 – 2018; 414 cases were reviewed by external
quality assurance associates.

4. The decision to cease the external quality associates’ contracts was
made in September 2018.

It is now more difficult to request a review of the final decision due to a reduction in the time from three months to one month which is compounded by the failure of PHSO to automatically provide the evidence relied upon, resulting in the need for lengthy subject access requests.

In the new PHSO service model, it is impossible for the complainant to challenge the scope of the investigation in order to ensure that all key points are covered. (see fourth bullet point in this list)

The whole investigation and review process is a secretive, closed-shop which is rigged against the complaint in a number of key ways giving rise to the repeated accusations of bias.

Proposal for academic research:

It can be seen that in its role as Health Service Ombudsman PHSO have failed to deliver improvements in patient safety. There is also evidence from Sir Liam Donaldson’s clinical review that the internal processes of investigation are subject to error of fact, error of interpretation and error of omission. The consistent narrative of service users is that such errors lead to bias and the failure to deliver justice. The evidence gathered for the recent clinical review provides significant new data about the current practice which could be explored further by academics. The twelve service users who attended the roundtable meeting with Sir Liam have been confirmed as ‘representative’ voices. Sir Liam also confirmed that their criticisms echoed those made previously, which remain unresolved. He stressed the importance of listening and learning from these criticisms in order to restore public confidence and effectively move forward. It can be seen that PHSO are culturally unable to carry out a meaningful review into their own practice. As part of the Manifesto for Ombudsman reform, the academics could learn much by examining in detail the case files of the twelve participants in the round table event and could widen their research to include the written evidence provided and source the case files from members of PHSOtheFACTS who contributed to the review directly through Sir Liam Donaldson. Independent academic research is needed to identify the areas where bias enters the process and to propose new quality control measures to ensure that final reports are totally free from bias as recommended by Sir Liam. Our collective lived experience has been repeatedly denied by those in a position of authority. Independent academic research is, therefore, essential and would contribute to the important debate surrounding the proposal for a new People’s Ombudsman.

Let us take this opportunity to work together and put the ‘people’s voice’ at the heart of the

‘People’s Ombudsman’

]]>https://phsothetruestory.com/2019/05/06/why-campaigners-need-academics-part-two/feed/11academic-proposalphsothefactsWhy campaigners need academics – part one.https://phsothetruestory.com/2019/04/23/why-campaigners-need-academics-part-one/
https://phsothetruestory.com/2019/04/23/why-campaigners-need-academics-part-one/#commentsTue, 23 Apr 2019 19:28:56 +0000http://phsothetruestory.com/?p=823We all need academics. They warn us when things aren’t working and they are a vital part of the debate on how to find better ways forward. They are highly respected because we believe that their research findings are robust. Not based on opinion which can be easily challenged, but on reliable evidence which has been thoughtfully considered from all sides to reach an unbiased conclusion.

Often through suffering personal injustice campaigners have become aware that aspects of society are not working and that this failure is causing harm. Campaigners are by default a minority group because instead of shrugging with resignation as most do, they work for change against a system which is slickly designed to resist such challenge. The media controls the narrative, the legal teams are funded by the bottomless pit of taxpayer money and battle-weary servants of the state can be refreshed with brand new faces who pile up the blame on those who went before giving everyone but the campaigners a ‘new start’. Those in authority label campaigners ‘unrepresentative’, a ‘small minority’ and ‘hostile’ in order to reduce their impact. Due to the intransigence of the state machinery campaigners need to have their voice amplified by the media, the courts or by independent, academic research for their message to be both heard and acted upon.

PHSOtheFACTS is a campaign group who have all suffered injustice at the hands of the Parliamentary and Health Service Ombudsman (PHSO) Dealing as it does with NHS complaints, the failure of PHSO can have deadly consequences. Since the arrival of Rob Behrens in April 2017 there has been a widespread acceptance that prior to this time PHSO had ‘lost its way’ and failed to deliver an acceptable service to the public. We saw the unprecedented actions of rebuke of the Ombudsman by the Secretary of State for Health, Jeremy Hunt, the resignation of the Deputy Ombudsman, Mick Martin, under a cloud of collusion, closely followed by the demise of the Ombudsman herself Dame Julie Mellor. With Ombudsman reform bubbling on the back burner this would be an ideal time for academics to research how this vital public service failed so spectacularly. It is clear that the internal checks and balances were inadequate and academic research could offer great insight on ways to design an accountable Ombudsman which would restore public confidence. So why isn’t this on the academic agenda?

Academic research requires funding and that funding comes directly from the government bodies who are the subject of the research. Too often the trigger for research is damage limitation following media or legal criticism. The organisation sets the terms for the project, supplies the data to be analysed and pays the piper for services rendered. You do not have to be overly cynical to see the obvious dangers of bias in this approach.

Bias through the control of the data:

Stung by media coverage of the relentless campaign by James Titcombe to have the Ombudsman investigate the avoidable death of his baby son, PHSO called in the services of Baroness Fritchie to review the way PHSO investigates avoidable death complaints. Because there was no computer tagging to identify such cases they were individually chosen by the PHSO staff who had handled them.

(1) It was not possible to identify these [avoidable death cases] from PHSO’s electronic caseworking system, so those staff who handle health complaints were asked to put cases forward. (p8)

Of the 100 cases put forward, 30 had received an investigation with 29 of those cases receiving an uphold, 10 were still at the assessment stage and 60 were closed without a full investigation. A surprisingly high figure of 59 cases had been allowed an investigation due to Ombudsman discretion as they had been submitted outside the statutory 12-month time limit. Did anyone check that this data was ‘representative’? Did anyone call for evidence to be submitted directly by complainants for comparison? There is no record this took place but this didn’t affect the outcome of the review being held in high regard, putting minds at rest that ‘something had been done’.

Bias by the dismissal of data:

In 2017 Martin Lewis from Money Saving Expert carried out consumer research regarding ombudsman services in the UK. Approximately 100 people completed the questionnaire regarding PHSO (p50). In his final report – Sharper teeth: the consumer need for Ombudsman reform Martin Lewis acknowledged the potential bias in self-selecting groups.

Respondents self-selected to take part in the survey, so it is to be expected that the results would be a little more negative than in a non-self-selecting poll (as people who have a complaint to make were more likely to participate). Despite this, the results were stark: (p2)

The findings were stark indeed. 82% said the handling of their complaint by PHSO was poor and 75% reported that the Ombudsman was biased against them. Valuable consumer data to feed into future research however this evidence was totally dismissed by an academic as ‘unrepresentative’ yet is it any more unrepresentative than 100 cases personally chosen by PHSO staff?

Bias by the omission of data:

In the Reseach Handbook of the Omudsmant here is a chapter entitled Ombudsmen: ‘hunting lions or swatting flies’. Having decided to focus attention on the PCA, more commonly known as PHSO, this academic then cites the LGO watcher for examples of the service user voice despite the fact that this campaign is specific to the Local Government Ombudsman and it has not been updated since 2016. She also cites a study by Creutzdelt and Gill (2015) which recorded the views of PHSOtheFACTS members, an active group, specifically focused on PHSO reform, yet none of our publicly available comments was included. It was as if we didn’t even exist. The whole concept of complaint handling as ‘swatting flies’ is dismissive of the importance of justice to the individual, suggesting that Ombudsman time would be better spent ‘lion hunting’ and uncovering national scandals. This was a debate framed to dismiss the importance of the citizen which was assisted by omitting the critical consumer voice.

Bias by failure to draw appropriate conclusions:

Looking at the issues of ombudsmen from a consumer perspective, Martin Lewis concluded that powers of enforcement were essential to Ombudsman bodies. He termed bodies without such legal powers as ‘flaccid’, serving no useful purpose, and complainants wholeheartedly agree with this logical viewpoint. In March 2019 following the release of the APPG report which supported these findings, a summary was written up for UKAJi.

“Linked to this a second recommendation is that schemes which do not have mandatory membership, nor binding recommendations should not be allowed to use the ombuds title (APPG Consumer Protection 2019).”ukaji.org/2019/03/18

No mention in this analysis that due to a lack of binding powers Rob Behrens at PHSO would no longer be able to use the title Ombudsman and the impact this would have on public confidence. Why not? Quite possibly because in academic circles the power of ‘own initiative investigation’ is given prominence. Indeed, own initiative powers may enable the Ombudsman to hunt down lions but without binding powers, he could only pull the trigger if the lion agreed to be shot.

Academic research into ombudsman services which fails to accurately record the consumer’s voice is flawed and proper reform made impossible by a collective failure to identify the real problems. Our lived experience does not sit well with academic models of how things should be and rather than challenge the theoretical assumptions it is easier to dismiss the dissonant views as invalid. For too long the voice of the citizen has been suppressed but when our voice is validated by others our call for change is more difficult to ignore. For things to improve we all need to acknowledge the real causes of failure and then set about putting that right. Tinkering at the edges of ombudsman reform has failed the public for the last 50 years.

In ‘Why campaigners need academics – Part 2’, PHSOtheFACTS will review supporting evidence and then suggest a viable academic research project. We welcome this opportunity to engage with the academic community.

]]>https://phsothetruestory.com/2019/04/23/why-campaigners-need-academics-part-one/feed/20academicphsothefactsIs the Parliamentary and Health Service Ombudsman impartial?https://phsothetruestory.com/2019/03/27/is-the-parliamentary-and-health-service-ombudsman-impartial/
https://phsothetruestory.com/2019/03/27/is-the-parliamentary-and-health-service-ombudsman-impartial/#commentsWed, 27 Mar 2019 21:03:21 +0000http://phsothetruestory.com/?p=801Since Rob Behrens became the Ombudsman in April 2017 he has been at great lengths to stress the importance of ‘impartiality’. In his pre-appointment hearing with PACAC (18.1.17) he confirmed that ‘impartiality’ was central to the role of the Ombudsman.

Once the ombudsman loses impartiality, he or she ceases to be an ombudsman and ceases to be independent. There always has to be that test, but you need to know that the ombudsman service has done as much as it can, and we have to explain that we are not the consumer champion but that we are an independent ombudsman service that has to adjudicate on the basis of the evidence that is available. Q 14

On the subject of evidence available, what evidence is there that the Ombudsman acts in an impartial manner when resolving complaints about government bodies and the NHS? There is absolutely no evidence to support this claim as there is no external scrutiny of the Ombudsman process, no external scrutiny of Ombudsman reports and the only body charged with any kind of external scrutiny – the Public Administration and Constitutional Affairs Committee (PACAC) chaired by Sir Bernard Jenkin have chosen not to scrutinise individual complaints. FOI request

What evidence is there that the Ombudsman is not impartial?

Quite a lot.

There is the fact that PHSO is Parliament’s Ombudsman, set up by legislation agreed in the House as a body to hold government departments, Ministers, MPs and civil servants to account. An inherent conflict of interests from the beginning. The Parliamentary Commissioner (PCA) later known as the Ombudsman was set up as an officer of Parliament designed to assist MPs in holding the executive to account via public complaint.

The PCA cannot be seen as independent of, and therefore is linked inexorably with, Parliament. In fact it would seem to be difficult to separate the PCA from Parliament without significant statutory changes. Denning Law

This report from Paul Burgess 1983 found that the Ombudsman did all in his power to accommodate the body under scrutiny, whilst ignoring the complainant and confirmed that a lack of external scrutiny had allowed the Ombudsman to be taken into the ‘bosom of the establishment’. Not an easy place to be if you are claiming to be impartial.

More recently the Patients Association(PA) wrote a number of damning reports about the work of the Ombudsman. In 2015 (following the publication of a previous report) over 200 people contacted PA to state their dissatisfaction with the Ombudsman service. The PA collated their responses in a report entitled Labyrinth of Bureaucracy where 66% stated that the final Ombudsman report was factually incorrect, inconsistent or substandard and 62% said that the Ombudsman overlooked evidence which contradicted the NHS Trust apparently siding with the Trust. Lack of impartiality was a repeated complaint.

Review request data indicates dissatisfaction with the Ombudsman investigation process and decision making. In 2017-18 complainants made 1,724 review requests. By contrast, only 17 review requests were made by public bodies. So for every 100 review requests made by complainants, only 1 review request was made by a public body. FOI request

This discrepancy is in keeping with a very low uphold rate. In 2017/18 only 2.6% of accepted formal complaints were upheld in full and only 12.2% were given partial uphold. The vast majority of people who complain to the Ombudsman go away with nothing.

Consumer feedbackdata is used by PHSO to demonstrate to PACAC the level of public confidence and satisfaction in the service. If the Ombudsman acted without impartiality then this should be highlighted in low consumer scores. In July 2016 PHSO changed their method for gathering consumer data and now compare external complainant feedback with an internal score generated by the Ombudsman as part of their Service Charter. They seek the complainants’ feedback on all key areas apart from Q10 which relates to the impartiality of the service. This omission has been criticised in the PACAC Annual Scrutiny Report 2016/17.

Impartiality and unconscious bias

47. The one commitment the PHSO’s service charter does not ask for complainants’ views on is number ten: “We will evaluate the information we’ve gathered and make an impartial decision on your complaint”.76 Many written submissions suggested that the PHSO’s investigators are biased towards professionals or the body being investigated, called ‘bodies in jurisdiction’ by the PHSO.77 In evidence Amanda Campbell told us, “I have exactly the same said to me from bodies in jurisdiction; they believe that we are biased towards complainants.”78

If the number of review requests is taken into account (as given above) it can been seen that for every dissatisfied body in jurisdiction there are 100 dissatisfied complainants so it would appear to be something of a glib response from Amanda Campbell CEO given the importance of impartiality to the very DNA of the Ombudsman service.

As public confidence relied upon the fact that the Ombudsman was seen to be impartial, PACAC requested that PHSO asked this question of complainants and published it as part of their service charter in the future. Although PHSO agreed to find a way forward on this by 2017/18 they were still not publishing on the specific question which dealt with impartiality. Consequently, Dr Rupa Huq a member of PACAC asked the following question in January 2019.

Last year the Committee recommended that as part of the service charter you ask complainants about whether they perceive you as impartial in your decision-making. How and when do you intend to do that? Oral evidence Q111

She was given a waffly response from Amanda Cambell CEO which suggested that securing this information was difficult but all they need to do is put Q10 of the Service Charter to the public as it is stated; We will evaluate the information we’ve gathered and make an impartial decision on your complaint. Why is PHSO so reluctant to put their ‘impartiality’ to the test?

Customer satisfaction data should act as a barometer of performance giving valuable feedback to both PHSO and PACAC. It is however, difficult to have any confidence in this data when the percentage scores fail to reflect the external criticism of this organisation. It has now been widely accepted that between 2012 and 2016, under the stewardship of Dame Julie Mellor, the Ombudsman service had ‘lost its way’.

“When I joined, it was an organisation in transition, which was not performing well. It wasn’t clear what its core role was anymore. My aim was to create an organisation that reflects the Ombudsman DNA – meaning being independent of bodies in jurisdictions, but also of complainants.”Interview with Rob Behrens June 2018

Yet the satisfaction scores under Dame Julie Mellor’s were higher than they are now under Mr Behrens leadership. Why didn’t these ‘independently gathered’ scores reflect the levels of dissatisfaction cited by the Patients Association, reported to PACAC by the public in numerous written accounts and now acknowledge by PHSO themselves?

In 2017 Martin Lewis and Money Saving Expert(MSE) carried out an independent survey of Ombudsman services. Approximately 100 people responded regarding PHSO and 82% said their experience was poor (p 54) with 75% saying they felt that PHSO was biased in favour of the other party (p 59) MSE-2017 These ‘independently gathered’ low-score figures are also replicated on other free-access consumer forums such as Google reviews and Trustpilot. Why is there such a disparity in scores?

If the PHSO customer satisfaction scores are an indicator of public confidence they are an unreliable one but as no other indicator exists, these are the scores which are repeatedly used to demonstrate approval. It can be seen that there has been no real movement over time but a rather static stodge of data.

Most recently Sir Liam Donaldson used these scores to determine that there was a level of customer satisfaction in the Ombudsman service. It would appear that he was not availed of this view from any other sources. Unusually, he had been able to take a peek behind the curtain of the secretive PHSO investigation process. Following an upheld judicial review against PHSO, Sir Liam was recruited as an independent expert to review the way PHSO used clinical advice in determining the outcome of investigations. His Clinical Advice Review was completed in December 2018 but not released until March 2019, after the annual PACAC scrutiny session which was held in January. Referring to the court judgement, Sir Liam cites the fact that the ‘internal’ world of PHSO where caseworkers remained convinced of the validity of their actions, clashed with the ‘external’ world where those actions were held to be perverse and illogical to the point of illegality. This goes to the very heart of ‘self-regulation’ and warns that PHSO should not be able to continually monitor its own performance without some form of external scrutiny. With direct access to caseworkers, clinical advisors and complainants Sir Liam had a rare opportunity to examine the whole investigation process. Although measured, his report reveals a system which is rife with opportunities for bias from the pre-determination of lay caseworkers who sift clinical evidence to present their preferred account, to the failure to provide all the evidence to the clinical advisors or allow them to give valuable input which goes beyond the narrow question base procedure and emphasised the failure to involve the complainant, often a key witness, until the process was complete.

With access to written transcripts, case studies, investigation reports and the attendance at a ’round table’ focus group meeting with twelve complainants, Sir Liam reported that the complainants told a consistent story and one which needs to be heard.

It would be wrong to simply note the critical comments and conclude that they were an unrepresentative minority. The sources of information on complainants’ experience provide rich and important insights into the functioning of the PHSO service. It was particularly striking that the group of complainants, with whom I, and the Clinical Advice Review Team, met, was not made up of vexatious or unreasonable people. They expressed frustration and, anger, but the problems that they described with the handling of their complaints should be a vital source of learning. Many of their criticisms of the PHSO’s processes, and those in the documented accounts and submissions, were consistent with what I had already observed, having read a sample of records provided to me. (p13)

Why would Sir Liam even consider that the views from complainants would be from an ‘unrepresentative minority’ who were ‘vexatious’ or ‘unreasonable people’? Where did that idea come from? Quite possibly from the Ombudsman himself who continually describes critics of his service in this disparaging manner. Here is Rob Behrens discussing the ‘user voice’ in a recent article written for ‘Research Handbook for the Ombudsman (p463)

Reading Sir Liam’s Clinical Advice Review it is obvious that there is no ‘clear and accessible policy framework’ and certainly not one which protects the public. There is also a great deal of evidence, as cited above, that the Ombudsman is not impartial, hence the dissatisfied users joining together. The fact that James Titcombe had to fight PHSO with ‘tenacity and resilience’ speaks volumes about the service he received. But let us ponder upon the full meaning of this statement for a moment and consider just who is claiming ownership of the ‘higher moral standing’ here.

“These users need to be reminded that while the complaint is their own,

the investigation and adjudications are the ombudsman’s …” Rob Behrens

]]>https://phsothetruestory.com/2019/03/27/is-the-parliamentary-and-health-service-ombudsman-impartial/feed/26Justice_Broken_ScalesphsothefactsWhose side is the Ombudsman on?https://phsothetruestory.com/2019/03/20/whose-side-is-the-ombudsman-on/
https://phsothetruestory.com/2019/03/20/whose-side-is-the-ombudsman-on/#commentsWed, 20 Mar 2019 09:04:55 +0000http://phsothetruestory.com/?p=793This is a question that only complainants seem to ask. Those in authority all colluding with the proposition that the Ombudsman is impartial. Rigorous academic research could provide the answer as data would have to be gathered from both sides. I wanted to present such an opportunity to the recent Administrative Justice Council pop up event (12th February 2019) where academics met to agree new research objectives. Unfortunately, after securing a ticket I was informed by Naomi Creutzfeldt, one of the organisers, that it would be inappropriate for a ‘hostile campaigner’ to attend as it might frighten off new researchers. When telling the truth about your own lived experience becomes ‘hostile’ you know things aren’t right in the academic world.

The ‘pop up’ was essentially a ‘pimping service’ where representatives from government bodies such as the Ministry of Justice (MOJ),Parliamentary and Health Service Ombudsman (PHSO) and Her Majesty’s Courts and Tribunals Service (HMCTS) could connect with researchers who were prepared to take payment for services rendered. Admittedly, that does sound rather hostile but they themselves accept there is a risk that their autonomy is jeopardised by the lure of government grants. Quote from their roundup session:

There is a risk that research will focus on what organisations or government want done, what data are available, or what funders are interested in, rather than on a consensus view of what is needed in the way of administrative justice research. Both Ministry of Justice and HMCTS are interested in working collaboratively with researchers and to have input on what data should be collected in evaluation work.

More than just a risk when other voices are actively kept out of the room. You can bet that both the MoJ and HMCTS will be interested in working collaboratively with researchers on data collection as by controlling the data you can control the outcome. On this point, it is interesting to note that academic Dr Chis Gill, lecturer in Public Law at the University of Glasgow recently informed PACAC (see Q9 )that he was particularly impressed with the consumer feedback gathered by PHSO and this data alone gave him confidence to confirm improvements in service delivery.

We were particularly impressed with the consumer data. That compares very favourably with consumer data collected by other public service ombudsmen. As to the scope of it and how it is collected, it is independently collected, and it is done in tandem with an internal QA process; all of that, to our mind, was very good-quality evidence that helped put in context some of the more acute issues that have maybe occurred in the past, with particular complainants being dissatisfied. That was one of the things that we built our level of confidence on in terms of this report.

This is despite the fact that PHSO act as a primary gatekeeper by controlling access to the customer survey in the first place. When did it become acceptable for academics to rely upon one source of evidence for their conclusions? (Kerching)

Way back in 2015, before they considered me to be ‘hostile’ I was asked by UKAJI to write a complainant’s eye view of the Ombudsman experience. Here are the key points I made:

No victim empowerment here; instead you become a victim all over again, a victim of the complaint process. Many regret that they ever took a case to the ombudsman, as it served only to compound their emotional stress; others wish that the body didn’t exist at all rather than raise false expectations.

Key obstacles

Some of the key obstacles faced by complainants are:

delay

lack of communication – you have to drive the case forward

secrecy – no knowledge of statements made by public body, though they are given access to your evidence

manipulation of the facts

factual error

staff away on leave regularly or case passed between staff so you start again with new case worker

blanket statements from staff which do not address key points raised

acceptance of statements made by public body at face value

refusal to release details of clinical advisor used – report written by clinical advisor – questions asked of clinical advisor or evidence supplied to clinical advisor

no action taken if a service delivery complaint made

any complaint made about the decision will be met with suggestion to go to judicial review

Since then we have been rather sidelined by the academic establishment and those in authority, notably the Ombudsman himself, Mr Rob Behrens, who describes us as a ‘small group of dissatisfied complainants’ who are unable to engage in ‘constructive dialogue’. Our first-hand experience just doesn’t sit well with the ‘open, transparent, impartial, remedy’ rhetoric regularly trotted out by the PHSO comms team. But now we find we are not alone. Concerns about the Ombudsman are as old as the Ombudsman office itself and way back in 1983 an academic/journalist named Paul Burgess actually talked to complainants in order to answer the question ‘Whose side is the Ombudsman on?’ and surprise, surprise the feedback from those complainants is an exact echo of our own concerns some 35 years later.

Published in New Society V55 on 13.1.1983 Mr Burgess opens with the following paragraph:

Whose side is the Parliamentary Ombudsman on? Is he the people’s champion against red tape and officialdom? Or is he an arbitrator seeking the middle way, the acceptable compromise between the aggrieved citizens and state bureaucracy? There is rising disquiet about the Parliamentary Commissioner for Administration, to give the Ombudsman his official title, and about his effectiveness in checking administrative abuse. Close scrutiny of some of his recent investigations suggests the disquiet is well-founded.

Openly criticising the Ombudsman was the first of many mistakes for Paul Burgess who was roundly slated for his article and no doubt told to tow the party line. He compounded his crime by including data to support his concerns and witness statements from complainants, Mrs Ward and Mrs Wilson breaking a number of unwritten rules.

rule no 1. – use only selective data to show how the Ombudsman service is improving

rule no 2. – never listen to complainants as they are unreliable narrators.

He foolishly pointed out that the Ombudsman has total discretion to cherry pick the cases to investigate in the first place and in 1983 just a third of the 1,031 complaints received an investigation. Paul Burgess was appalled to learn that in 1981 it was even worse with fewer than one if four of the 917 complaints being taken up for investigation. He was clearly concerned about the many dissatisfied citizens who were simply turned away from the only arbiter who could assist them so heaven knows how he would feel to learn that in 2017/18 the Ombudsman investigated just 8% of the 32,389 complaints which came his way and upheld just 3% of all those complaints. This is a shocking statistic of failure to deliver justice and remedy to the public but one which gets little attention.

Paul Burgess revealed that customer satisfaction was low.

The eventual outcome, after investigation of the cases he accepts, is apparently satisfaction for less than one in eight of all complainants. What has gone wrong?

With only a 3% uphold rate satisfaction in the Ombudsman has gone from bad to worse. Perhaps if the Burgess article had opened up an honest debate at the time, things would have improved but unfortunately, his article was stifled by the academic establishment.

There has always been some confusion about the role of the Ombudsman and Rob Behrens uses this to good effect with claims that ‘the public do not understand’ and ‘they expect us to deal with their issues’ and when disappointed with the results the public are to blame for not being able to ‘manage their expectations’. Back in 1983 Paul Burgess understood the role to be;

Constitutionally, his job is to protect the citizen from maladministration and to pursue officialdom for unjust treatment.

If protecting the citizen is the primary role, then the Ombudsman is failing 97% of the citizens. By default, the actual role must be to protect the government from findings of maladministration as the Ombudsman has consistently achieved low uphold rates for the last 50 years. Paul Burgess goes into some detail of Mrs Ward’s case who actually received an upheld verdict on her complaint about the DHSS but was distressed by the failings of the investigation process. This is an interesting example for analysis as the well-rehearsed line on disgruntled complainants is that they are dissatisfied because they didn’t get the decision they were looking for. Well, Mrs Ward did get the decision she was looking for but the process was long-winded, opaque, riddled with error and failed to take note of anything she had to say. That sounds familiar. Here are a few snippets from Paul Burgess analysis which chillingly chime so accurately with our own experiences:

… in an investigation which took a year, he [the Ombudsman] made no contact at all with the complainant. Consequently, relying upon the DHSS version of events, he got his facts wrong. As it happens, Mrs Ward is a diary-keeper and could have given him a detailed record at least as reliable as that of the DHSS local office.

When pressed by George Morton her MP to explain this interpretation of an impartial investigation, Clothier [Ombudsman] replied that the DHSS files had provided ‘ample’ information. He was not, of course, to know that the local office involved had acquired some notoriety among welfare rights workers, and was indeed found by an independent appeal tribunal, within a year of his report, to have fabricated evidence against a claimant.

You don’t have to be an academic to spot that if the Ombudsman relies on evidence from only one-side this would prevent fabricated evidence coming to light. An easy thing to put right but this still happens at PHSO who allow government departments to tell their own story without probing or correlation to the facts. Some would call this bias, in fact, most reasonable people would call it bias for bias it is.

Paul Burgess also notes an aspect of the Ombudsman’s reports he terms ‘accommodating observations’ aimed to give balance where none is deserved. Bending over backwards could be another apt description.

Scattered through the report are accommodating observations about the DHSS. This is a common feature of his reports in general and contributes significantly to the overall ‘tone’. Legal obligations fulfilled by the DHSS are presented as concessions – the back-dating of the invalidity pension for Philip, when in fact good cause had been legally established; and the writing-off of an over-payment which was caused by yet another mistake at the local office and was therefore not recoverable.

Many who receive long-awaited PHSO reports are surprised to find that despite acknowledging damning evidence of failure to follow written procedures resulting in harm to the citizen the Ombudsman is prepared to reserve negative judgement on the basis that the organisation has informed them that it has since improved or on the basis that even if procedures had been followed the same harm would most likely have occurred. The Ombudsman in full limbo dancing mode whilst holding aloft a crystal ball.

Paul Burgess also used the case of Mrs Wilson to demonstrate how the Ombudsman manipulated the facts to show the government body in the best light. Mrs Wilson received uphold in two of her three complaints but was dissatisfied with the service stating that ‘the system to which he belongs does not understand what ordinary people want from the Ombudsman.’ How very true.

The report says, “The local social security office were not to know that the rules governing Family Income Supplement were about to be changed.” But two months previously, the DHSS had announced the forthcoming change. It seems reasonable to expect the Ombudsman to establish that the local office should have known; Mrs Wilson did!

Paul Burgess throws caution to the wind when he goes on to criticise parliament’s select committee which is the only body charged with holding the Ombudsman to account.

The Ombudsman is responsible to MPs and to parliament through a select committee. Unfortunately, apart from the occasional splutterings, the committee appears to be singularly docile. Its reports have a complacent, self-congratulatory air. Most disturbing of all is its failure to prevent the Ombudsman from being taken to the bosom of the Establishment.

If you are snuggled inside the bosom of the Establishment as the Ombudsman most surely is, protected on all sides from proper scrutiny, then it is impossible to call yourself ‘impartial’. The figures alone tell the story as year after year the Ombudsman dismisses without uphold well over 90% of the complaints it receives. But try telling that to the academics or the media and you will be met with a roll of the eyes as they encounter yet another hostile citizen hell-bent on revenge. Let us leave the last word to Paul Burgess who reveals the truth having spoken to complainants themselves and studied first-hand the Ombudsman reports, something which is unheard of today. He also sets a challenge for those now working in the field of administrative justice in his final conclusion.

At grassroots level, I believe the ombudsman scheme has been a failure. It does not offer the ordinary citizen a satisfactory remedy against administrative abuses; indeed, it has become a part of the oppressive network of official institutions which, though purporting to offer public service, have effectively acquired purposes and justifications of their own. This failure was anticipated by some people from the beginning. The late J.D.B. Mitchell, former Professor of Constitutional Law at the University of Edinburgh, argued; “Public authorities have moral responsibilities and these moral responsibilities can never be translated into legal responsibilities without a specific system of public law.”

So who is going to fund the academics to put out papers on the moral v legal responsibilities of the Ombudsman? Any offers, anyone at all ….

]]>https://phsothetruestory.com/2019/03/20/whose-side-is-the-ombudsman-on/feed/21whose-side-is-the-ombudsman-onphsothefactsBeyond the yellow brick road. Allyn Condon’s fight for justice.https://phsothetruestory.com/2019/03/11/beyond-the-yellow-brick-road-allyn-condons-fight-for-justice/
https://phsothetruestory.com/2019/03/11/beyond-the-yellow-brick-road-allyn-condons-fight-for-justice/#commentsMon, 11 Mar 2019 17:01:20 +0000http://phsothetruestory.com/?p=790Editors note: As you follow the ‘yellow brick road’ on Allyn Condon’s fight for justice for his baby son’s avoidable death you will find that the NHS story keeps changing and changing again. Despite hard evidence of the failure of Bristol Children’s Hospital they have obfuscated at every turn. Deny, delay, defend in action. You can follow Allyn Condon’s journey here

To all NHS staff if you have the time to read the following it may inform you in some of your future decision making, in regards to your patients and their families. I hope in some part what I have written can be of help to you and the future of the NHS.

I must first state that my intention in writing this letter is not to in anyway harm or harass anyone and not to cause any alarm or distress. All information provided in the document is truthful and therefore will not constitute any libel, defamation or any other similar claim.

My aim is not to be vexatious, nasty or personal but merely to present facts of the matter allowing people to make up their own mind and to use the information as they see fit.

The path which I am currently on was chosen by NHS staff, not myself, or any member of our family. Unfortunately this path does not have yellow bricks or an Emerald City at the end of it, of that I can assure you.

I have however offered on many occasions the opportunity for NHS staff who chose this path, a way to get off and that is by offering the truth, a truth that should have been offered from day one but wasn’t. Nevertheless I would once again state that without the truth it will take more than the wonderful Wizard of Oz to put an end to this journey.

I have followed recent medical cases and one in particular and it was clear that the outcome was not a big favourite with the NHS fan club. An outcome that has been fiercely contested. From my little knowledge as a mere mortal I have gathered that there have been several breakdowns and misunderstandings along the way.

Based on my above experience I would like to once again publicly offer all involved in our own case, the opportunity to stand up and break ranks by coming forward and being honest. A big ask I know but if you don’t ask, you don’t get. For anyone involved, I offer the opportunity to be removed from any further involvement in what has already turned out to be a messy case. For those involved in the case who wish to remain silent, then that is indeed a choice that will no doubt come with future consequences and I hope that the consequences are not met with outrage and anger from the NHS fraternity who will be able to recognise that several windows of opportunity were given for the truth to be told.

Now I must reiterate that my intentions are not to cause any harm or distress or to harass any individuals and my actions must certainly not be constituted as a threat but how shall we say it, more of a promise. I will pursue this for as long as it takes and along the way I will ensure I publicly expose those involved over and over again with factual evidence. I will be relentless in my pursuit of justice at whatever cost. My actions may appear futile in the rose tinted eyes of some NHS staff, but to me, it is the opposite action that is being used to meet the original action.

If you know any of the people involved and feel it may be within there interest then feel free to forward on this letter and maybe one day they will thank you for helping them out. Maybe one day as a valued worker within the NHS you may also recognise the choices they made were the wrong ones and the consequences which followed could have been avoided with the truth.

So let me explain exactly what I am talking about.

NHS staff were responsible for the death of our two month old baby boy Ben, a death they subsequently covered up. Some will argue that they never covered up his death they covered up the negligent failings which led to his death, potato potahto.

The level of care they offered our son on the intensive care unit at Bristol Children’s Hospital fell way way way below the expected level, to a level we believe is criminal. Now I know some medics at this point will be sighing that another family are pursuing the excellent staff that just made a little mistake but hear me out.

Whilst Ben was on the PICU ward in Bristol, staff failed to appropriately monitor his temperature leaving him hypothermic for days on end, failed to appropriately monitor his ventilation despite his condition requiring optimum ventilation management, told us Ben was of no concern to them and that others could die, showing a total lack of respect and total complacency around Ben’s illness. Staff failed to carry out appropriate or regular monitoring despite the suspicion of a bacterial infection waiting over 40 hours to take tests, twice. Failed to carry out blood tests despite saying they had, failed to carry out blood cultures despite saying they had, failed to administer antibiotics for 3 days despite suspecting a bacterial infection, failed to take any action after Ben turned blue and wasn’t ventilating, left him without senior care for 6 hours whilst blue and deteriorating, decided to give antibiotics but failed to do so for 9 further hours, prescribed antibiotics for chest Sepsis and forgot to give them for a further 6 hours, administered a drug days outside protocol causing collapse and hours later Bens death.

Now I think any credible medic will agree that the standard of care fell way below what was expected, especially considering Ben was on what would be considered by some to be one of he most reputable children’s wards in the country. Any medic who disputes this falls way below an expected level, has no place in our NHS. Facts are facts.

So what else did they do?

After discovering a positive bacterial infection, they failed to tell our family about the result for 12 months, yes 12 months. They failed to add any reference to the bacterial infection in any medical records before, during or after Bens death, failed to carry out a post mortem after telling us one was not necessary, failed to add the hospital acquired infection to the death certificate. Staff also failed to contact the Coroner claiming that the death was expected despite all Doctors stating they were shocked when Ben died and it was unexpected.

So we all make mistakes and we all forget a few things here and there so I don’t want to be too hard on these Doctors. I mean surely they would just tell us what happened and we could all live happily ever after.

They failed to provide us with a discharge or death summary, failed to offer any bereavement support, failed to contact us after Ben died and later claimed they had but claimed they never left a message as they didn’t want to bother us.

We then met Consultants 7 weeks after Ben died were they finally told us 50 minutes in to a meeting that Ben had developed a secondary bacterial infection. The honesty was overwhelming. They then went on to lie saying they never knew about the infection until long after death, lied telling us they had carried out blood tests and blood cultures and lied stating the both bloods and cultures were negative. No tests were ever taken when they claimed. We also know it was the infection that brought the Consultants to the bedside. How does something bring you to the bedside that you claim to only have known about 12 months after death. Honestly I am not kidding 12 months after death they disclosed the result that was reported hours before Ben died. You couldn’t even make it up if you tried.

Following the meeting where they told us they never knew about the infection before Ben died they later sent internal emails discussing the positive result before death. Good honest Doctors. More lies.

They were investigated for their lies. The outcome was they didn’t mean to lie. The person who investigated them was one of their colleagues. They were that close she failed to even take a statement off one Doctor. An independent investigation decided the investigation was not appropriate or robust. No further investigation was done.

The Chair of Child Death Review removed references to failings, references to deteriorating blood results, references to inappropriate ventilation management and references to hypothermia. She also withheld the Child Death Review minutes for 18 months, coincidentally until one week after the inquest, claiming they did not exist. When we finally received them they disclosed more recognition of failings and failures in protocol. It was finally admitted in the Child Death Review that Ben had died of Pseudomonas, Pseudomonas Sepsis, Sepsis Syndrome, Septicaemia, Sepsis. Interestingly enough despite it being a hospital acquired infection the microbiologist claimed that the infection had come from our home water and refused to accept it was hospital acquired. I think the tests on admission they did, or claim to have done may prove that theory wrong.

A further meeting we discussed in detail Bens care and discussed the poor level of care. We discussed that it was disgusting that Ben wasn’t given antibiotics and was told that they had forgotten, but that they were also not necessary. We left the room and staff admitted that we were right and that antibiotics should have been given days earlier. We know they admitted this because they were recorded, not only on our recording but also on their own. After they admitted we were right they realised the recordings were still on and conspired to delete the hospital recording and attempted to delete our recording. Unfortunately they failed to delete ours so therefore could not delete their own despite agreeing to delete it after the meeting had finished.

They were investigated for conspiring to delete the recordings. The outcome was they didn’t mean to say it and there comments were said in haste. The person who investigated was one of their colleagues. An independent investigation decided the investigation was not appropriate or robust. A further investigation was done coming to the same conclusion. The Trust refused to release the investigation stating it was on the advice of their legal team. Open, honest and transparent? You make up your own mind.

The investigator removed all reference to failings stating they were not relevant. Candour? I think not.

In a further meeting the silence was broken. They admitted, we got it wrong and we are sorry. We missed the infection and we are sorry for not getting in and treating it. We should have given him antibiotics days earlier and had we done so they would have treated him. They admitted that all involved agreed that Ben should have been given antibiotics earlier. They agreed that when Ben was blue that was the Sepsis getting hold of him. They told us that they were not covering. This was six months post mortem. Imagine being a family and hearing this. A mixture of hurt at knowing he could have been saved and relief that we now knew.

From this day onwards they changed their mind, they changed their story. From when they admitted they should have given antibiotics, apparently he no longer died of an infection.

An inquest 18 months after Ben died they all told the Coroner there was never any sign of an infection, antibiotics were never needed and antibiotics would not have saved Bens life. They all told the Coroner that Ben died of an air leak around his heart, an air leak that caused a cardiac arrest and caused Bens death. What they told the Coroner was more lies. Interestingly enough the Coroners own independent expert told the same lie. Collusion? Not for me to say.

They knew they had administered a drug Day’s out of a documented protocol which had caused the air leak and the cardiac arrest but claimed Ben had deteriorated with an air leak before the drug was given. This was despite previously telling us that Ben was stable at this stage. But that was the other story. More lies, more inconsistencies and most of all absolute perjury committed by all Consultants at the inquest. The Coroner said she was not willing to comment on their lies.

They told us he had an infection they missed, they told the Coroner he didn’t. They told us antibiotics would have treated him, they told the Coroner they wouldn’t. They told us antibiotics should have been given earlier, they told he Coroner they shouldn’t. They told us there is no way we can say he had an air leak before he had a cardiac arrest, they told the Coroner the air leak caused the arrest. More lies and more cover up, absolute perjury.

They told us the Pseudomonas infection had brought Consultants to the bedside and they told the Coroner they knew about the infection that night. We know there are five Doctors who knew about that infection before Ben died. The Trust claim it was only a trainee who knew and he took no action. They knew and the Trust CEO still claims today that they didn’t. They won’t admit they knew because when they do we start again. Why did you not document? Why did you not tell the parents? Why was it not on the death certificate? Etc etc. Let’s just blame the trainee who has currently been left out of the picture but will no doubt be pursued at some point for his lack of effort to take action on a dying baby after he found out he had an infection.

Oh and just to top all this off after two and a half years they finally admitted liability for the negligence that led to Bens death and claim they had only just realised.

Now after all of the above I once again offer each and everyone of them an opportunity to clear their name, to be honest and to do exactly what should have been done from day one. If they are being forced to lie then say so and we will leave them alone. Of course they need to say who by. If they feel out evidence is wrong, just let me know I will remove it.

Dr Jess Spaull Junior Doctor

Dr Suzanne Dean Paediatric Consultant

Dr James Fraser Paediatric Consultant

Dr Matthew Christopherson Paediatric Consultant

Dr Peter Davis Paediatric Consultant

Dr David Grant Paediatric Consultant

Dr Margrid Schindler Paediatric Consultant

Dr Ian Jenkins Paediatric Consultant

Bryony Strachan Chair of Women and Children’s Services

Rebecca Dunn Deputy Divisional Director

Ian Barrington Divisional Director

Sean O’Kelly Medical Director

Robert Woolley Chief Executive

Profession Michael Stevens

Dr Jane Luker Deputy Medical Director

Each and every one of the above have played their role either negligently allowing Ben to die, causing death through reckless practice, conspiring to cover failings and delete evidence, inappropriately investigating covering failings, withholding evidence, lying about failings, lying about test results & perjury.

I will continue to expose each and everyone now and forever more with factual evidence. If what I was saying was not true it would be removed and I would be in court for defamation. Ask yourself why I am not? I was arrested twice for harassment for exposing them. The cases were dropped. It was just an attempt to discredit me and my own unblemished character.

I will ensure that all future employers are aware and all family and friends. I am not harassing anyone, I am presenting facts. I will be like the news channel in their life that never turns off presenting old news over and over again to new people. I will keep going until everyone knows, every colleague and every person.

If anyone believes anything I have written is incorrect and would like to discuss it and prove me wrong I will remove it.

I hope they take me up in my offer, it may save their careers. I hope that other medics realise that lying and covering a baby’s death is not cool, it ruin lives. Think before you lie.

This is not Kansas and I am not Dorothy.

This is real life and Ben was a living breathing little boy who they left to die and covered up his death.

These Doctors are not the victims of my repetitive campaigning, they are the victims of their own selfishness. They are what is destroying the NHS whilst people sit back and blame everything else.

Ask yourself, is this the NHS you signed up to work in? Are these the people you thought you would be working with?

This is not system failure due to shortage of staff or any other reason. This is individual failings and individual lies that have failed the system, failed the NHS and failed our family. There are no excuses!

]]>https://phsothetruestory.com/2019/03/11/beyond-the-yellow-brick-road-allyn-condons-fight-for-justice/feed/9yellow brick roadphsothefactsFraud, what fraud? Part 4 – Action Fraud.https://phsothetruestory.com/2019/02/25/fraud-what-fraud-part-4-action-fraud/
https://phsothetruestory.com/2019/02/25/fraud-what-fraud-part-4-action-fraud/#commentsMon, 25 Feb 2019 17:11:21 +0000http://phsothetruestory.com/?p=780In Fraud, what fraud? part 1 we learnt that members of staff at The Parliamentary and Health Service Ombudsman (PHSO) contacted me in April 2018 concerned that management at the Ombudsman’s office were condoning fraud. See extract below from Fraud, what fraud? part 1

In the last financial year (2017/18) PHSO has underspent. The issue with underspending is that previous year spending is used to calculate how much funding PHSO gets for the next year. This caused management in PHSO to panic. As a result, they promoted overtime close to the year-end (last two weeks has seen the biggest overtime promotion). Frontline staff were encouraged to claim overtime. The overtime rate for caseworkers was £45 an hour plus a bonus for doing 3.5 hours or more. That rate for a public sector organisation is criminal. In addition to this crazy overtime rate, staff were actually told to claim overtime even though they did not work. Staff were encouraged to fudge their timesheets. That is a fraud. I am sure that is illegal and can no longer watch this type of thing happening. Managers and staff in the operations team openly over claim in their time sheet to do reduced hours of work and to take extra time off in lieu, but this is taking this issue to another level.

As management were actively promoting these fraudulent overtime payments the staff members were unable to effectively raise their concerns and asked me to call for a full investigation. I tried to secure the data which would show a spike in overtime/bonus payments for the end of the financial year (2017) to support these claims, only to be told that PHSO held no records of individual payments due to outsourcing to a third (private) party. Accusations of fraudulent payments and lax record keeping were, in my opinion, the business of the National Audit Office (NAO)who could carry out a full investigation. However, in Fraud, what fraud -part 2 we learnt that remarkably the NAO were unable to investigate without the agreement of PHSO and that was hardly likely to happen.

I was hoping that the Public Administration and Constitutional Affairs Committee (PACAC) would pick up on this whistleblower claim of fraudulent spending in their annual scrutiny meeting with PHSO. I submitted evidence to the committee in December 2018 who had a focus on ‘value for money’ yet no questions were asked of the Ombudsman, Rob Behrens or the CEO Amanda Campbell. You can read the details here: Fraud, what fraud – part 3

I now had only one option left. A report to Action Fraud as recommended by the NAO who considered this to be the ‘appropriate authority’ for my concerns. From the Action Fraud website it did not appear that this was the most obvious place for an accusation of institutional fraud committed by a public body.

We provide a central point of contact for information about fraud and financially motivated internet crime. People are scammed, ripped off or conned everyday and we want this to stop.

The service is run by the City of London Police working alongside the National Fraud Intelligence Bureau (NFIB) who are responsible for assessment of the reports and to ensure that your fraud reports reach the right place. The City of London Police is the national policing lead for economic crime.

However, given this was my only option I attempted to contact Action Fraud and share my information. I thought that email would work well as I could forward on the message I received from the whistleblowers or failing that print it out and send it by post. I was surprised to find that Action Fraud have neither an email address or a postal address. (It’s almost like they don’t want the information) You can complete an on-line form but it required that I put in the name of the person who witnessed the fraud and I did not have that name so couldn’t get past the gateway. I checked Action Fraud out on twitter and asked them if they could send me a postal address as I had information I wanted to send. They did not reply. I browsed through their site and the following comments did not give me confidence that I had finally found the organisation to take notice of these serious fraud allegations.

And indeed it turned out that Action Fraud (you can contact them by phone but be very, very patient) only take a note of your concerns and do not investigate but use the information to form a ‘picture’.

When you report to us you will receive a police crime reference number. Reports taken are passed to the National Fraud Intelligence Bureau. Action Fraud does not investigate the cases and cannot advise you on the progress of a case.

No investigation unless my information is supported by others to ‘form a picture’. I wondered why the NAO recommended such an option – didn’t they know this would happen? I had come to the end of the road.

So what is to stop PHSO management from encouraging inflated overtime payments again as the financial year draws to a close? Well, absolutely nothing. NAO office can’t investigate, PACAC are not inclined to investigate and Action Fraud, representing the police will only investigate if there is substantial evidence from a range of sources. Welcome to Great Britain – #corruptbydesign.

]]>https://phsothetruestory.com/2019/02/25/fraud-what-fraud-part-4-action-fraud/feed/34Fraud-Stamp-624x499phsothefactsFraud, what fraud? part 3 PACAChttps://phsothetruestory.com/2019/02/23/fraud-what-fraud-part-3-pacac/
https://phsothetruestory.com/2019/02/23/fraud-what-fraud-part-3-pacac/#commentsSat, 23 Feb 2019 19:37:01 +0000http://phsothetruestory.com/?p=776PACAC is the Public Administration and Constitutional Affairs Committee. Under a different name this particular select committee first came into existence to monitor the work of the Parliamentary Commissioner – later termed the Parliamentary Ombudsman. The committee members have always had a difficult time being both the champions of the Ombudsman on the one hand, charged as they are with ensuring that Ombudsman reports about government bodies are acted upon. Then on the other hand holding the Ombudsman to account on behalf of parliament and the public. A kind of good cop/bad cop all rolled into one cop. It would appear from this Denning Law Journal that the committee originally acted as an appeal/review body for dissatisfied complainants and MPs.

For many years this Committee has served as a form of appeal/review from the PCA’ s decisions as to whether or not to investigate a complaint. If an M. P. or complainant is unhappy with the outcome, they are usually referred to the Select Committee. The Committee will investigate the complaint and can call the PCA to account for his decision.

That must have become rather irksome for the members of the committee as somewhere along the line they managed to narrow their role to examining the Annual Report released by the Ombudsman. As luck would have it in December 2018 PACAC put out a request for written evidence on the performance of the Ombudsman with particular reference to ‘value for money’. After the 2016/17 scrutiny meeting PACAC called for an external audit of PHSO given ‘its past problems’.

However, we also agree with the Ombudsman that before the PHSO can make the case for more funding, it will need to demonstrate that it is spending its current funding well. Given its past problems an external audit mechanism is required that will provide robust assurance of the value for money of the PHSO’s operations to its Board, the Committee and the public. We recommend that the Ombudsman asks his non-executive directors to commission this, and report back to us.

‘Robust assurance’ was called for so PACAC would be keen to learn about the alleged fraudulent overtime payments The ‘past problems’ no doubt referred to the National Audit Office Procurement Report which you can read more about here

Following the NAO investigation into ‘perceptions of procurement misdemeanors’ in 2013 a number of governance recommendations had been made. It would be an ideal time for the NAO to follow-up and assure themselves and parliament that their recommendations had been properly applied. However, it was not the NAO who were called in but Peter Tyndall, Ombudsman for the Republic of Ireland (as chair of the team) along with Caroline Mitchell, Lead Ombudsman of the FOS (Financial Ombudsman Services and recently the subject of a Dispatches expose). You can see Peter Tyndall here in the blue mac with PHSO Ombudsman Rob Behrens (front left) out visiting the Lowry exhibition in Salford. It’s good to see that they all get on so well isn’t it.

Strangely, the review team were completely satisfied with the financial monitoring and governance at PHSO. They clearly had not been informed of the accusations of fraudulent payments of overtime or that PHSO held no monthly records of payments to staff. See fraud, what fraud? part 1 PHSO

The review team didn’t say an awful lot on this subject to be honest. They said that things had ‘improved’ were ‘enhanced’ and ‘better’ without any reference to how they stood before or after. Peer Review Study Sounding a little like Anna Rampton, Director of Better in the spoof programme W1A this was their only comment on the subject.

5.2. Financial monitoring and governance arrangements have been improved, with enhanced financial literacy in key roles and a governance framework that supports better decision-making;

Better than what?

Clearly the review team were unaware of the accusations of fraud and it was my responsibility as a dutiful citizen to ensure that PACAC knew that all was not as it seemed. Consequently, I took the time to write a full report to PACAC and included the following passage.

Whistleblowers reported to PHSOtheFACTS discrepancies in bonus and overtime payments made by PHSO at the end of the 2017 financial year. A FOI request confirmed that PHSO do not hold data on individual payments made to staff for bonus or overtime due to contracting out to a third party. Without the data it is difficult to know how PHSO will defend against such accusations which are presently being reported to Action Fraud.

I kept it short and sweet but gave enough information for the committee to ask some serious questions at the oral scrutiny session in January. Such as;

Why did whistleblowers go out to a third party when the PHSO has a policy on protecting whistleblowers.

Why don’t PHSO keep accurate records of payments made to individual employees and how can they monitor for internal fraud without such records?

How did any fake claims for overtime or bonus pay avoid the scrutiny of financial monitoring and governance?

Pretty obvious questions yet somehow, in the mix of things, they all got overlooked. The clerks had read the evidence, the MPs had read the evidence and Sir Bernard Jenkin,Chair of PACAC has read the evidence yet not one single question on the accusations of fraudulent payments, whistleblowing or the lack of accurate records. Remarkable eh?

Also, no connection was made with the results of the 2018 PHSO staff survey which was part of the evidence from PHSO to the committee. Evidently, only 48% of staff felt it was safe to challenge the way things were done and with an 80% response rate perhaps the other 20% didn’t feel it was safe to complete the survey. Who knows. External whistleblowing has to be a worrying sign, a cause for concern but apparently it didn’t concern PACAC. In fact the only person who did contact me with some concerns was Shaun Lintern from the Health Service Journal to find out if I could identify the whistleblowers. Unfortunately, I couldn’t but good of him to ask.

]]>https://phsothetruestory.com/2019/02/23/fraud-what-fraud-part-3-pacac/feed/5Fraud-Stamp-624x499phsothefactsCulturally CosySafe to speak up 2018